Chronic Disease Management Part 3

Stanley Feld M.D.,FACP,MACE

This blog is dedicated to Joan Colgin R.N., MSN the best Diabetes educator I have ever met. Joan Colgin R.N. is dedicated to the nursing tradition that the patient is first. She is dedicated to helping the physician help the patient.

You recall I asked you to image you have discovered you have Type 2 diabetes. I have provided you with an understanding of the pathophysiology of Type 2 Diabetes Mellitus. You understand why you have an elevated blood glucose level. I reviewed the devastating effects an elevated blood glucose level can have on your eyes, kidneys, nerves and heart.

Now I need to tell you what must be done to enable you to control your blood glucose level to prevent the chronic complications of Diabetes. I understand some people learn faster than others. Some people have so much fear and anxiety about diabetes that they have a very difficult time understanding what has to be done.

The basic educational process initiated by the physician must be reinforced by the Diabetes Education Team (DET). The DET must be an extension of the physician’s care in order for them and the educational process to be effective. It is very important that there are no contradictions in the educational process.

In 1995 the American Association of Clinical Endocrinologists (AACE) published Diabetes Guidelines: Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management.

These guidelines were updated in 2002. This system of care was developed by Endocrine Associates of Dallas P.A. We developed a Diabetes Education Center within the practice. Joan Colgin R.N.,MSN. was the chief nurse educator. The physicians, the nurses and the dieticians worked together as an integrated team. We learned a great deal from patients and from each other. We figured out how to teach patients with various learning skills how to become the professor of their diabetes.

We learned that the patient must make a commitment to become as knowledgeable as possible. The patients had to learn how to self-manage their disease and understand the meaning of the results of home glucose monitoring. You will see in the AACE guidelines a Patient Physician contract. (p78)

Patients have to commit themselves to become the professor of their disease and the physician and his team commit themselves to teach the patients how to control their disease.

The AACE guidelines also contain as series of test questions of the patients’ knowledge. (p71-77). The correct answers are starred. Patients are tested at the onset of the education process and at the end of the course. The recommendation is that the education should be given on an individual basis so teaching can be customized to the patient’s learning skill. The test is repeated at 6 months to determine how much the patient has retained. If there are areas of weakness in understanding they can be addressed.

In the process of follow up with the physician the patients are taught to question their reaction to medication and make suggestions to the physician about changes in therapy.

If the physician discovers areas of patient misunderstanding that will hinder the patient’s self-management, the DET can reinforce the education in that specific area. The goal is to normalize the HbA1c in order to avoid complications of Diabetes Mellitus.

This is a very powerful process of care. The difference between the 2002 AACE Diabetes guidelines and other chronic disease guidelines are they are patient centric. Most guidelines are physician centric. Empowering the patient can improve control of blood glucose levels and thus prevent the complications of diabetes.

It introduces the process of rapid cycle improvement into the care of chronic disease management. The care of the patient is led by the patient’s input and participation in the treatment decision making process. The adjustments to therapy are not led by periodic static testing in the physician’s office. Periodic testing is simply a snapshot of the disease process. It tells us the results of the previous care. It is not proactive and tells us little about the changing disease process.

It has been stated most patients are not smart enough to learn about their disease and participate in the care of their disease. I recently received a comment from Dino Ramzi’s expressing this.

“I also know patients who do not have the intellectual capacity to understand the information they are being presented, despite our use of video, comic books and printed material to explain the principles of self-care. Some are too financially constrained or socially overwhelmed to do the right thing. Sometimes paying the rent and putting some food on the table is more important than exercising or taking your pills. Other patients are too depressed to motivate themselves to proper self-care. Others seem to have had some unpleasant interactions with the healthcare system or perhaps a personality disorder (this is a somewhat charitable way of describing the peculiar dysfunctional manipulations of a sorry minority).

The grand fallacy of relying on personal responsibility is that people have at their disposal all the choices to be made. The worst can’t do better.”

I agree with Dino Ramzi’s comment to some extent. However, many people who fit into his categories have not been given the opportunity or financial incentive to learn about their disease. Some patients cannot be motivated to self manage their disease because of their social circumstance. However, with focused training and financial incentive a great number of these people will respond.

However, these patients represent a very small minority of the patients with Type 2 Diabetes Mellitus. Our present system is not effective in decreasing their complications of diabetes. These patients will have complications in any system.

I am talking about the patients that want to learn and self manage their disease. The goal is to educate and motivate the great majority of people who are capable of learning and taking responsibility for their care.

Michelle Sobel, chief creative officer for Emmi Solutions, Inc, a Chicago-based company that produces interactive patient education videos expressed the concept beautifully, “The engaged patient is more than an informed patient. The engaged patient is activated. She understands information critical to her health, communicates effectively and confidently with her clinical team, complies with instructions related to her treatment, and is positively transformed by her experience with care.”
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You will recall the adherence/compliance rate for the treatment of most chronic disease has been studied to be only 40-50%. By engaging patients to be proactive in the care of their disease the adherence/compliance rate increases to up to 90%. Only with the appropriate treatment and the appropriate patient adherence to treatment will we decrease the costly complication rates of chronic diseases.